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The Egyptian Journal of Hospital Medicine (January 2019) Vol. 74 (4), Page 752-763
257 Received: 12/10/2018 Accepted: 01/11/2018
Adherence of surgeons to surgical prophylaxis guidelines
Alshehri Ibrahim M.1, Albishry Ibraheem M.2, Alharthi Khuwailid R.3, Al Qarni Bader A.4*
1 Inpatient Pharmacy Supervisor, Rabigh General Hospital, Jeddah,2 Rabigh General Hospital,
Pharm.,D 3 King Abdullah Hospital, Bishah, BPharm, Pharm.,4 Al-Thagar General Hospital, Jeddah,
BPharm, Pharm.
Corresponding author: Al Qarni, Bader Ayed, Training and Education Section Supervisor, Al-Thagar General Hospital,
Jeddah, BPharm, PharmD, MClinPharm. [email protected].
Abstract
Background: surgical site infections (SSIs) are microbial contamination of the surgical wound during
a period of one month that could result in major post-operative morbidity and mortality rates.
Objectives: this study aimed to identify the adhesion of surgeons to antibiotics prophylaxis guidelines
at Kingdom of Saudi Arabia (KSA). Methods: this study included 180 adult subjects who were
scheduled to undergo major surgeries in the hospital. The data of the patients were collected from the
surgical wards and day care unit. Results: most of the included surgeons showed no error during pre,
intra and post operative duration as give the required antibiotics and didn’t give the non-require
antibiotics. The preoperative adherence of surgeons as most of the surgeons (73.9%) followed the
prophylactic measures that included correct choice, indications, dosage and duration. Most of the
surgeons (76.1%) followed the prophylactic measures including correct choice, indications, dosage and
duration during intra-operative period. The majority of the surgeons (75%) followed the prophylactic
measures including correct choice, indications, dosage and duration during post-surgical duration.
Conclusion: The level of surgeon’s adherence to antibiotic prophylactic guidelines was efficient among
most of surgeons regarding the proper choice of antibiotic, duration, timing and indication. However,
these results differ from other available studies, this study showed a good sign for application of
antibiotic prophylactic measures in KSA hospitals. Further studies should be conducted to increase the
knowledge and adherence of surgeons all over KSA.
Keywords: adherence, prophylactic measures, antibiotic prophylaxis guidelines, surgeons, KSA,
2018.
Introduction
Surgical site infections (SSIs) are
microbial contamination of the surgical wound
during a period of one month. SSIs could result
in major post-operative morbidity and mortality
rates that increases the costs of treatment on
populations and health authorities (1, 2). The SSI
annual prevalence in the United States was
about 1.07% resulting in 8000 deaths every year
with more than10 billion dollars for treatment (3). Also, in the United Kingdom, SSI was
responsible for increasing the length of the
hospital stay from 5-17 days and extra cost for
each case by about 3394 dollars (4, 5). About
40% of surgical infections were found to be
SSIs (6) thus prevention and implementing of
antibiotic prophylaxis projects could reduce the
rates of SSIs which in turn would decrease
hospital stay, ICU admission and costs for
further treatment (7-10). The antibiotic
prophylaxis programs are defined as the
administration of antibiotic medications before,
during or after the surgery to decrease the risk
of infection and its consequences (11, 12). They
were recommended for clean, contaminated as
well as dirty procedures to avoid specific
criteria of risk factors for infection (12-15).At
first, the type of surgery must be determined
then implanting a protocol for proper
prophylactic program. Also, popper time,
efficiency, advantages and complications must
be taken into consideration before, during and
after the surgery. The greater the adhesion to
the surgical antibiotic prophylaxis would
significantly decrease the rates of anaphylactic
shock and diarrhea induced by antibiotic usage.
Another aspect that necessitates adhesion of
surgeons to antibiotic prophylaxis programs is
to reduce the resistance pattern of microbes to
antimicrobial agents. This study aimed to
identify the adhesion of surgeons to antibiotics
prophylaxis guidelines.
Rational and hypothesis:
Alshehri Ibrahim et al.
257
The antibiotic prophylaxis guidelines
are the most effective programs for prevention
of surgical infections during and after surgery.
The lack of knowledge, education and adhesion
to these programs would increase the risks of
SSI which would increase the costs of
treatment, increase the mortality and morbidity
rates as well as admission to ICU and the length
of hospital stay. Assessing the practice and
adherence pattern will improve the knowledge
and practice of surgeons and overcome the
increased risks of surgery infections.
Objectives:
- General objectives:
1- Assessing the adhesion of surgeons to
antibiotics prophylaxis guidelines.
- Specific objective:
1- Increasing the attention of Saudi
surgeons toward the usage of antibiotic
prophylaxis guidelines.
Methods:
Study design:
An observational cross sectional
hospital based survey.
Setting: The study was carried out at the Rabigh
General Hospital from January 2018 to March
2018.
Study population: This study included adult subjects who
were scheduled to undergo major surgeries in
the hospital. The exclusion criteria were
infant’s surgeries, cancer, refusal of the patients
and contaminated surgeries.
Study population and sample size:
With regards to the number of surgeries
in the department during the last 12 months a
sample of 180 surgeries were chosen to
participate in the study during the study period.
Study tools and data collection:
The data of the patients were collected from the
surgical wards and day care unit. All the data
from the patient’s files were collected and
divided into three main parts which include pre-
operative, intra-operative and post-operative
antibiotic prophylactic measure which were
compared with the international programs.
Also, the main outcome measures will include
the suitability of indicted prophylactic
antibiotic, the antibiotic choice, dosage of
administration, timing and duration.
Limitation of the study:
- There is a lack of studies conducted in
KSA about this subject. Limitations of
time, number of included cases and
access to all patient’s files.
Ethical considerations:
A written approval was provided from
the supervisors regarding the aim of the study.
The questionnaire will be validated by 3
supervisors. An informed contest was given by
all participants who approved to take part in the
study.
Statistical analysis: The data processing was done using
SPSS for windows (version 22). The
descriptive variables will be shown as
frequencies and percentages.
Results:
Tables 1 and 2 showed the demographic
characteristics of the included patients
including distribution of age and gender
(Figures 1 &2). The studied patients were
distributed according to their hospital stay as
shown in table. 3 and figure 3.
Table 1: distribution of the studied group regarding their age
Number Percent
> 40 yrs. 54 29.9
40-50 44 24.6
> 50 yrs. 82 45.5
Range
Mean
S.D.
26-67
48.3
12.6
Adherence of surgeons to surgical prophylaxis guidelines
257
Figure 1: distribution of the studied group regarding their age
Table 2: distribution of the studied group regarding their gender
Gender Number Percent
Male 90 50.0
Female 90 50.0
Total 180 100.0
Figure 2: distribution of the studied group regarding their gender
Table 3: distribution of the studied group regarding their hospital stay (days)
Number Percent
2-3 51 28.3
4-6 74 41.1
> 7 55 30.6
Total 180 100.0
29.9
24.6
45.5
Age
> 40 yrs.
40-50
> 50 yrs.
5050
Gender
Male
Female
Alshehri Ibrahim et al.
255
Figure 3: distribution of the studied group regarding their hospital stay (days)
- Type of surgery:
The patients were distributed according to the type of surgery as most of the subjects were having
upper and lower abdominal surgery (28.9%) followed by 24.4% for gynecological surgeries then
emergency surgeries (16.7%), 15.6% for head and neck surgeries and q4.4% for orthopedic surgeries
(Table 4 and figure4).
Table 4: distribution of the studied group regarding their surgery type
Number Percent
Upper and lower abdomen 52 28.9
Orthopedic 26 14.4
Head and neck 28 15.6
Emergency 30 16.7
Gynecological 44 24.4
Total 180 100.0
Figure 4: distribution of the studied group regarding their Surgery type
- Surgery class:
Most of the included surgeries were clean (91.7%) and 8.3% were contaminated (Table 5and figure
5).
Table 5: distribution of the studied group regarding their surgery class
Number Percent
Clean 165 91.7
Contaminated 15 8.3
Total 180 100.0
28.3
41.1
30.6
Hospital stay (days)
2-3
4-6
>7
15
13.9
14.4
15.6
16.7
24.4
Surgery type
Upper abdomen
Lower abdomen
Orthopedic
Head and neck
Emergancy
Gynacological
Adherence of surgeons to surgical prophylaxis guidelines
257
Figure 5: distribution of the studied group regarding their surgery class
- Pre-operative prophylactic measures:
Most of the included surgeons showed no error among 73.9% who give the required antibiotics and
5% among those who don’t require antibiotics. Only 21% of errors were shown as 15% administrated
non required antibiotics and 6.1% of surgeons didn’t give the required antibiotic (Table .6, figure. 6)
Table 6: distribution of the studied group regarding their pre operative prophylactic measures
Number Percent
No error
Required and administrated 133 73.9
Not required and not administrated 9 5.0
Error:
Not required but administrated 27 15.0
Required but not administrated 11 6.1
Total 180 100.0
Figure 6: distribution of the studied group regarding their pre operative prophylactic measures
Intraoperative prophylactic measure:
Most of the surgeons showed no error during the surgery as 76.1% of patients were administrated the
required doses, while the intraoperative error was 11.7% among patients. On the other hand 10% of
the patients were not detectable about their intraoperative prophylactic measures.
91.7
8.3
Surgery class
Clean
Contaminated
01020304050607080
Pe
rce
nt
Pre operative prophylactic measures
Alshehri Ibrahim et al.
252
Table 7: distribution of the studied group regarding their intra-operative prophylactic measures
No error Number Percent
Required and administrated 137 76.1
Not required and not administrated 4 2.2
Error
Not required but administrated 14 7.8
Required but not administrated 7 3.9
Total 180 100.0
Figure 7: distribution of the studied group regarding their Intra-operative Prophylactic
measures
- Postoperative prophylactic measures:
Most of the surgeries showed no error among 75% and 3.3% of patients but 16.7% of patients were
administrated non required doses of antibiotics and 5% were not administrated their required
antibiotic doses.
Table (8): Distribution of the studied group regarding their Post operative Prophylactic measures
No error Number Percent
Required and administrated 135 75.0
Not required and not administrated 6 3.3
Error
Not required but administrated 30 16.7
Required but not administrated 9 5.0
Total 180 100.0
01020304050607080
Pe
rce
nt
Intra-operative Prophylactic measures
Adherence of surgeons to surgical prophylaxis guidelines
257
Figure 8: distribution of the studied group regarding their Post operative Prophylactic
measures
- Antibiotic choice:
Table 9 showed that the most commonly used antibiotic were cefixime and metronidazole followed
by Celphaosprorin and penicillin (Table 9 and figure 9). The dosage of administration were once or
twice among most of the subjects (Table10 and figure 10)
Table 9: distribution of the studied group regarding their antibiotic choice
Number Percent
Cefixime 43 23.9
Metronidazole 43 23.9
Penicillin 30 16.7
Celphaosprorin 34 18.9
Cephalexin 10 5.6
Azithromycin 9 5.0
Fluroquinolones 11 6.1
Total 180 100.0
Figure 9: distribution of the studied group regarding their antibiotic choice
01020304050607080
Pe
rce
nt
Intra-operative Prophylactic measures
23.9
23.9
16.7
18.9
5.65
6.1
Antibiotic choice
CefiximeMetronidazolePenicillinCelphaosprorinCephalexinAzithromycin
Alshehri Ibrahim et al.
257
Table 10: distribution of the studied group regarding their dosage of administration
Number Percent
Once 89 49.4
Two 80 44.4
Three 11 6.1
Total 180 100.0
Figure 10: distribution of the studied group regarding their dosage of administration
Preoperative adherence of surgeons:
Table 11 showed the preoperative adherence of surgeons as most of the surgeons (73.9%) followed the
prophylactic measures including correct choice, indications, dosage and duration, 4.4% followed the
correct choice and dosage while 21.7% followed only the correct choice.
Table 11: distribution of the adherence pattern among the surgeons: pre-operative
Number Percent
Correct choice, indications, dosage and duration 133 73.9
Correct choice and dosage 8 4.4
Correct choice 39 21.7
Total 180 100.0
Figure 11: distribution of the studied group regarding their adherence pattern among the
surgeons Pre-operative
- Intraoperative adherence:
Most of the surgeons (76.1%) followed the prophylactic measures including correct choice,
indications, dosage and duration, 3.9% followed the correct choice and dosage while 10% followed
only the correct choice and 10% were not applicable.
49.4
44.4
6.1
Dosage of administration
Once
Two
Three
73.9
4.4
21.7
Adherence pattern among the surgeons
Pre operative
Correct choice,
indications, dosage
and duration
Adherence of surgeons to surgical prophylaxis guidelines
277
Table 12: distribution of the adherence pattern among the surgeons: intra-operative
Number Percent
Correct choice, indications, dosage and duration 137 76.1
Correct choice and dosage 7 3.9
Correct choice 18 10.0
Not applicable 18 10.0
Total 180 100.0
Figure 12: distribution of the adherence pattern among the surgeons: intra-operative
Post-operative adherence:
The majority of the surgeons (75%) followed the prophylactic measures including correct choice,
indications, dosage and duration, 10.6% followed the correct choice and dosage while 14.4% followed
only the correct choice.
Table 13: distribution of the adherence pattern among the surgeons: post-operative
Number Percent
Correct choice, indications, dosage and duration 135 75.0
Correct choice and dosage 19 10.6
Correct choice 26 14.4
Total 180 100.0
Figure 13: distribution of the adherence pattern among the surgeons post-operative
76.1
3.9
10
10
The adherence pattern among the surgeons
Intra-operative
Correct choice,
indications, dosage
and durationCorrect choice and
dosage
75
10.6
14.4
The adherence pattern among the
surgeons Post operative
Correct choice,
indications, dosage
and durationCorrect choice and
dosage
Alshehri Ibrahim et al.
277
Discussion The surgical site infection is considered one of
the most common risk factors for nosocomial
infections resulting in high mortality rates (16).
The antibiotic prophylactic measures pre, intra
and post-surgery could reduce the morbidity
and mortality related infections (17, 18). A little is
known about the adherence of surgeons to
American Society of Health-System
Pharmacists Surgical Antibiotic Prophylaxis
Guidelines in KSA. This study showed good
rates of adherence to prophylactic procedures
among most of the surgeons during the pre,
intra and post-surgical procedures. In Tokyo,
the adherence rates to the antibiotic selection
were high ranging from 53-84% and the
adherence to the timing and duration was lower
but still high reaching to 68% (19).
Stimulatingly, in France, about 49% of
surgeons were adherent to the prophylactic
measures for a period of two years (20).
However, these results were in contrast of other
studies that showed poor rates of prophylactic
guidelines adherence (11, 21). Also, other studies
have shown low levels of adherence among
surgeons and this could be attributed to
ignorance of the prophylactic measures and
improper over-prescription (22, 23). Another
study showed a low level of adherence to all the
guidelines aspects (28%) among Dutch
hospitals (24). Higher rate of non-commitment to
proper antibiotic, dosage, duration and timing
selection which were contract to our results as
the levels of errors were not that high and the
level of compliance to prophylactic measures
was good enough among most of the subjects (9,
25-27). The same results were found in Canada
with a low adherence levels as only 32% of
patients received the recommended prophylaxis (28). Supplementary, the adherence to the
antibiotic prophylaxis duration was
inappropriate among 65% of the surgeries (29).The present study showed that the most
commonly used antibiotic were cefixime and
metronidazole. The dosage of administration
was once or twice among most of the subjects.
The same results were reported in Abdel-Aziz
et al. (9) study shows that cefazolin (44.6%) was
the most frequently used antibiotic and other
studies declared that cephalosporin antibiotics
were the preferred choice in most of surgical
procedures (30). Also, cephalosporin and
ceftriaxone were used as the drug of choice in
most of studies but excessive use of ceftriaxone
could result in antibiotic resistance (11, 21).
Conclusion
The level of surgeon’s adherence to antibiotic
prophylactic guidelines was efficient among
most of surgeons regarding the proper choice of
antibiotic, duration, timing and indication.
However, these results differ from other
available studies, this study showed a good sign
for application of antibiotic prophylactic
measures in KSA hospitals. Further studies
should be conducted to increase the knowledge
and adherence of surgeons all over KSA.
Ethical considerations:
A written approval was provided from the
supervisors regarding the aim of the study. The
questionnaire was validated by 3 supervisors.
An informed contest was given by all
participants who approved to take part in the
study.
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